The University of Akron IdeaExchange@UAkron The Dr. Gary B. and Pamela S. Williams Honors Honors Research Projects College
Fall 2018 The ffecE t of Breastfeeding and Rooming-In Care on Neonatal Abstinence Syndrome Rachel Boyer The University of Akron, [email protected]
Lindsay Gal The University of Akron, [email protected]
Mahaylie Cline The University of Akron, [email protected]
Please take a moment to share how this work helps you through this survey. Your feedback will be important as we plan further development of our repository. Follow this and additional works at: https://ideaexchange.uakron.edu/honors_research_projects Part of the Congenital, Hereditary, and Neonatal Diseases and Abnormalities Commons, Maternal, Child Health and Neonatal Nursing Commons, Obstetrics and Gynecology Commons, Pediatrics Commons, Substance Abuse and Addiction Commons, and the Women's Health Commons
Recommended Citation Boyer, Rachel; Gal, Lindsay; and Cline, Mahaylie, "The Effect of Breastfeeding and Rooming-In Care on Neonatal Abstinence Syndrome" (2018). Honors Research Projects. 785. https://ideaexchange.uakron.edu/honors_research_projects/785
This Honors Research Project is brought to you for free and open access by The Dr. Gary B. and Pamela S. Williams Honors College at IdeaExchange@UAkron, the institutional repository of The nivU ersity of Akron in Akron, Ohio, USA. It has been accepted for inclusion in Honors Research Projects by an authorized administrator of IdeaExchange@UAkron. For more information, please contact [email protected], [email protected]. Running head: THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON 1
The Effect of Breastfeeding and Rooming-In Care on Neonatal Abstinence Syndrome
Rachel Boyer, Mahaylie Cline, and Lindsay Gal
The University of Akron
Author Note
Rachel Boyer, Department of Nursing, The University of Akron; Mahaylie Cline,
Department of Nursing, The University of Akron; Lindsay Gal, Department of Nursing, The
University of Akron.
Correspondence concerning this paper should be addressed to Carol Scotto, Department of Nursing, The University of Akron, Akron, OH 44325.
E-mail: [email protected] THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 2
Abstract
Concurrent with a rise in opioid abuse during pregnancy is an increase in the number of babies born with Neonatal Abstinence Syndrome (NAS). Despite this crisis, no single treatment has been identified for NAS. This paper sought to analyze and synthesize research evaluating the effectiveness of breastfeeding and rooming-in care on the need and length of pharmacologic treatment and length of hospital stay for neonates with NAS. Twenty-six peer reviewed research articles published between 2006 and 2017 were selected from PubMed and CINAHL for analysis. The studies focused on neonates with NAS born to mothers addicted to opioids or undergoing opioid maintenance treatment (OMT). The studies reviewed included systematic reviews and research studies utilizing control and intervention groups in various countries with sample sizes ranging from 16 to 952 neonates. Findings indicate that breastfeeding and rooming-in are effective for mild-moderate NAS whereas pharmacologic treatments are recommended for moderate-severe NAS. In addition to these findings, this paper will discuss limitations faced while compiling research and the possibility for future research and implementation into practice.
Keywords: neonatal abstinence syndrome, pregnancy, post-natal care, breastfeeding, rooming- in care, length of stay, substance abuse, opioids
THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 3
The Effect of Breastfeeding and Rooming-In Care on Neonatal Abstinence Syndrome
Over the last twenty years, there has been a significant rise in the number of pregnant women who are addicted to drugs, specifically opioids, during their pregnancy. Concurrent with an escalation in opiate prescription abuse, there has been a five-fold increase in the occurrence of pregnant women using opiates from 2000 to 2009 (Forray, 2016). As of 2012, a national survey found that illicit drugs were used by 5.9% of pregnant women in the United States (Forray,
2016). This has resulted in an equally significant rise in the number of neonates born with
Neonatal Abstinence Syndrome (NAS), which is the result of the sudden cessation of fetal exposure to any substance abused by the mother during pregnancy (Kocherlakota, 2014).
Because opioids mainly affect the central nervous system and gastrointestinal tract, common signs and symptoms of NAS in neonates include: irritability, increased wakefulness, high- pitched crying, repeated yawning and sneezing, exaggerated deep tendon reflexes, increased muscle tone, tremors, seizures, inadequate feeding and weight gain, uncoordinated continuous sucking, and temperature instability (Hudak et al., 2012). Between 2009 and 2012, the occurrence of NAS jumped from 3.4 to 5.8 per 1,000 hospital births in the United States (Patrick,
Davis, Lehman, & Cooper, 2015). Between 2004 and 2013, the incidence of NAS soared from 7 to 27 out of every 1,000 Neonatal Intensive Care Unit (NICU) admissions (Raffaeli et al., 2017).
According to Centers for Disease Control and Prevention (CDC), the rate of NAS increased five- fold from 2000 to 2013 (Barfield, Broussard, Yonkers, & Patrick, 2016). In 2012, the CDC stated that every 25 minutes a neonate was born with NAS in the United States (Barfield et al.,
2016). There were approximately 21,732 neonates identified with NAS in 2012 in the United
States alone (Patrick et al., 2015). THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 4
Mothers suffering from drug addiction during pregnancy generally live high risk lifestyles that lead to a variety of social, nutritional, physical, and mental health problems
(Kocherlakota, 2014). Social issues of pregnant addicts include participation in illegal activities, inability to access appropriate birth control, decreased likelihood of attending prenatal care visits, and an increased likelihood of smoking and drinking alcohol (Ashraf, Ashraf, Asif, & Basri,
2016). A nutritional issue common to pregnant addicts is malnourishment (Ashraf et al., 2016).
Physical issues that are common among pregnant addicts include irregular menstruation, amenorrhea, anemia, hypertension, diabetes mellitus, heart disease, increased risk of infection, and inadequate oral hygiene (Ashraf et al., 2016). Mental health issues among pregnant addicts include postpartum mood disorders and depression (Pritham, 2013). Due to these issues, women addicted to opioids during their pregnancy have six times the risk of developing obstetric complications, including abruptio placenta, premature rupture of membranes, preterm delivery, preeclampsia, and postpartum hemorrhage (Ashraf et al., 2016). Additionally, maternal drug addiction puts the neonate at risk for intrauterine growth restriction, congenital anomalies, cognitive defects, prematurity, low birth weight, respiratory distress syndrome, and NAS (Ashraf et al., 2016; Raffaeli et al., 2017). These complications of maternal and neonatal lifestyle result in an increased need for pharmacologic treatment, increased length of hospital stay (LOS), and increased medical costs (Raffaeli et al., 2017). Due to increased cost of care and increased LOS, it was estimated that hospital charges for NAS care in 2012 was $1.5 billion (Crook & Brandon,
2017).
With a rise in neonates born with NAS, it is important for nurses to be prepared to use evidence-based practice to effectively care for neonates born with NAS. The current issue nurses are facing is that there are heterogeneous standards of care across hospitals globally for THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 5
treating neonates with NAS. According to Kocherlakota (2014), there is no single standard treatment regimen accepted for NAS due to the complicated and indistinct nature of withdrawal in neonates and the effects of illicit drugs. Because thorough research has not been performed to determine the most effective treatment for NAS, nurses are left to treat neonates based on individual hospital policy rather than on what is best for the neonate. By initiating a standard plan of care founded on evidence-based practice across hospitals globally, there is potential to improve patient outcomes and decrease healthcare costs.
In order to establish a foundation for evidence-based practice, it is important to identify which treatments are currently in practice, including pharmacologic and nonpharmacologic interventions. Three common pharmacologic interventions used to treat NAS are morphine, methadone, and buprenorphine. These substances are all opioids, which consist of endogenous and synthetic drugs that mainly act on opioid receptors in the central nervous system to elicit analgesia (Hudak et al., 2012). Both morphine and methadone are opioid agonists and buprenorphine is an opioid mixed agonist-antagonist (Hudak et al., 2012). These opioids have each been used to treat NAS in neonates, but morphine is currently the preferred treatment
(Kocherlakota, 2014). Neonates who receive pharmacologic treatment have an average LOS of
23 days (Patrick et al., 2015). Two common nonpharmacologic interventions used to treat NAS are breastfeeding and rooming-in care. Breastfeeding (the feeding of milk produced by the mother to her neonate) and rooming-in care (the method of tending to both mother and baby in the same room beginning directly after birth) have both been identified as treatments that decrease the severity of NAS symptoms in neonates (Abrahams, MacKay-Dunn, Nevmerjitskaia,
MacRae, Payne & Hodgson, 2010; Kocherlakota, 2014). THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 6
The aim of this systematic review is to clarify what is known about the effect of breastfeeding and rooming-in care on the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay with neonates suffering from NAS. This systematic review is guided by the following question: In neonates with NAS, what is the effectiveness of nonpharmacologic interventions (including breastfeeding and rooming-in care) instead of or in addition to pharmacologic interventions such as opioid maintenance treatment
(OMT) compared to exclusive OMT on decreasing the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay?
Methods
The search focused on research studies about neonates with NAS. The mothers described in these studies were either currently addicted to opioids and other addictive substances or undergoing OMT. The studies included both pharmacologic and non-pharmacologic interventions, including morphine maintenance treatment, buprenorphine maintenance treatment, methadone maintenance treatment, breastfeeding, and/or rooming-in care. The timeline observed in these studies included the treatment of NAS in neonates from time of birth to discharge from a healthcare facility. The studies were published in peer reviewed medical journals published between 2006 and 2017 found through CINAHL and PubMED databases.
When searching the CINAHL and PubMED databases for research studies, the following keywords were used in a variety of combinations: neonatal abstinence syndrome, breastfeeding, rooming-in care, drug therapy, opioid maintenance treatment, methadone maintenance treatment, methadone, buprenorphine, and nonpharmacologic treatment. Seventeen results were found when the keywords neonatal abstinence syndrome, breastfeeding, and opioid maintenance treatment were collectively searched on PubMed. Fifty-two results were found when neonatal THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 7
abstinence syndrome, breastfeeding, and drug therapy were collectively searched on PubMed.
Two results were found when neonatal abstinence syndrome, rooming-in care, and opioid maintenance treatment were collectively searched on PubMed. Eight results were found when neonatal abstinence syndrome and rooming-in care were collectively searched on PubMed. One hundred and one results were found when neonatal abstinence syndrome and buprenorphine were collectively searched on CINAHL. Six results were found when neonatal abstinence syndrome and rooming-in care were collectively searched on CINAHL.
After each initial keyword search brought back a list of search results, studies from that results list were first eliminated if the title of the study was irrelevant to the treatment of neonates with NAS. If the studies were still relevant, their abstracts were examined to determine if the content of the study was relevant to the treatment of neonates with NAS. If the studies were irrelevant, they were discarded; if the studies were relevant, their entire contents were thoroughly read to determine if the studies examined how each NAS treatment affected the outcomes described in the research question. The outcomes described in the research question include the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay for neonates suffering from NAS. If one or all of these outcomes were measured, the study was included in this systematic review. In total, twenty-six research studies met the criteria previously stated and were included in this systematic review.
The journals used in this review were selected based on their relevance to the keywords and if they met the criteria established before conducting the research. The use of the two databases CINAHL and PubMed ensured a comprehensive review of available studies related to the topic at hand. This review sought to avoid bias by including studies with multiple points of THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 8
view about the effectiveness of nonpharmacologic and pharmacologic treatments used to treat
NAS.
Results
There were twenty-six research studies included in this systematic review. This section will provide detailed information on the sample setting, sampling method, sample size, study design, level of evidence, and specific findings of the research studies included in this systematic review. The specific findings will describe the conclusions reached regarding the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay.
Sample Setting
An extensive review of the literature revealed that studies about nonpharmacologic treatments for neonates with NAS have been conducted across the globe. Included within this systematic review are two studies from Australia, two from the United Kingdom, six from
Canada, six from the United States, and one from Norway. Considering the worldwide interest in this neonatal health problem, nurses should seek out research that supports effective evidence- based practices to care for neonates born with NAS.
Two studies were performed at hospitals in Australia, with one study located in
Randwich, New South Wales and one study located in Western Sydney (Abdel-Latif et al., 2006;
Liu, Juarez, Nair, & Nanan, 2015). Two studies were performed at hospitals in the United
Kingdom, with one performed in London and the other in Glasgow (Dryden, Young, Hepburn &
Mactier, 2009; Saiki, Lee, Hannam & Greenough, 2010). One study looked at 18 different hospitals in Norway (Welle-Strand, Skurtveit, Jansson, Bakstad, Bjarkø & Ravndal, 2013).
Six studies were performed at hospitals in Canada. Three of the six studies were performed in Vancouver, one of which was specifically performed at the Fir Square Unit of BC THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 9
Women’s Hospital (Abrahams, Kelly, Payne, Thiessen, Mackintosh & Janssen, 2007; Abrahams et al., 2010; Hodgson & Abrahams, 2012). One of the six studies was performed at hospitals in
Vancouver, Toronto, and Montreal (Ordean, Kahan, Graves, Abrahams & Kim, 2015). Two of the six studies were specifically performed at Kingston General Hospital in Ontario (McKnight et al., 2015; Newman et al., 2015).
Five studies were performed at hospitals in the United States. Four of the five studies were located in the northeastern states, including Pennsylvania, New York, New Hampshire, and
Maine (Brown, Hayes & Thornton, 2015; Holmes et al., 2016; Kraft et al., 2008; Kraft et al.,
2017). The two studies located in Pennsylvania were both conducted at the Thomas Jefferson
University Hospital (Kraft et al., 2008; Kraft et al., 2017). One of the five studies was located in the Midwest state of Ohio (Isemann, Meinzen-Derr & Akinbi, 2011).
Five studies were systematic reviews that pulled the research necessary for their reviews from several online databases, including PubMed, Ovid Medline, Embase, CINAHL, Medline, and Cochrane (Bagley, Wachman, Holland, & Brogly, 2014; Boucher, 2017; Holmes, Schmidlin
& Kurzum, 2017; Kocherlakota, 2014; Pritham, 2013). Four studies were performed at unspecified hospitals, clinics, or treatment programs (Crook & Brandon, 2017; Hudak et al.,
2012; Jansson et al., 2008; O’Connor, Collett, Alto & O’Brien, 2013). One study was a compilation of current medical research and expert opinion discussing NAS (Raffaeli et al.,
2017). Given the national and international interest in this topic at prestigious institutions, synthesis of study results and further research is certainly warranted.
Sampling Method
Among the 26 studies included in this systematic review, a common methodology is evident with noticeable similarities and differences. The overwhelming majority of studies THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 10
utilized a control group compared with one or more intervention groups. The minority of studies used databases to synthesize evidence from research studies to draw a conclusion about the effectiveness of one or more interventions.
Fourteen studies followed two comparison groups during a specific length of time.
However, these 14 studies did not use the same type of comparison groups or conduct research during the same time periods. Seven of the 14 studies used a comparison group of formula-fed neonates with a comparison group of breastfed neonates suffering from NAS (Abdel-Latif et al.,
2006; Dryden et al., 2009; Isemann et al., 2011; Jansson et al., 2008; Liu et al., 2015; O’Connor et al., 2013; Welle-Strand et al., 2013). Three of the 14 studies used a comparison group of neonates with NAS rooming-in with their mothers and a comparison group of neonates with
NAS admitted to the NICU (Abrahams et al., 2010; Newman et al., 2015; Ordean et al., 2015).
One of the 14 studies specifically used a comparison group with and a control group without prenatal family education, increased family involvement in symptom monitoring as well as in nonpharmacologic treatment, and rooming-in care (Holmes et al., 2016). One of the 14 studies used a comparison group of neonates with NAS who received buprenorphine and a comparison group of neonates with NAS who received morphine (Kraft et al., 2017). One of the 14 studies used a comparison group of neonates with NAS who received methadone and a comparison group of neonates with NAS who received morphine (Brown et al., 2015). One of the 14 studies used a comparison group of neonates with NAS who received buprenorphine and a comparison group of neonates with NAS who received neonatal opium solution (NOS) (Kraft et al., 2008).
Three research studies used two comparison groups in which both groups collected data at different periods of time. These three studies used the same type of control and comparison groups, but did not conduct the research over the same time periods. The control group consisted THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 11
of a group of neonates suffering from NAS who were admitted to the NICU, while the comparison group consisted of neonates with NAS that practiced rooming-in with their mothers
(Abrahams et al., 2007; McKnight et al., 2015; Saiki et al., 2010).
One research study looked at one cohort over a specific length of time (Hodgson &
Abrahams, 2012). The cohort was made up of mother-neonate dyads who were cared for through a rooming-in care program. The medical charts of these dyads were reviewed and data was collected regarding the type of drug used by the mother, maternal methadone dose at the time of delivery, and whether or not the neonate required morphine treatment.
One research study used three comparison groups in which each comparison group had data collected at different periods of time. This study used a comparison group of neonates with
NAS before specific changes in interventions occurred, a comparison group after Baby Friendly
Status (BFS) was implemented, and a comparison group after BFS plus breastfeeding education was implemented (Crook & Brandon, 2017). Baby Friendly Status in this particular study is defined as a quality improvement program which promotes breastfeeding through the healthcare structure and practices (Crook & Brandon, 2017). There are ten steps involved in achieving
BFS, some of these include: allowing mothers and neonates to remain together 24 hours a day, training the staff how to implement this policy, encouraging breastfeeding on neonate command, and giving neonates no drinks other than breast milk (Crook & Brandon, 2017).
Five of the studies were systematic reviews. These studies used databases to find research articles relating to the topic at hand. The keywords used to find the studies for these five studies included, but were not limited to, LOS, breastfeeding, nonpharmacologic treatment, rooming in, swaddling, and NAS (Bagley et al., 2014; Boucher, 2017; Holmes et al., 2017;
Kocherlakota, 2014; Pritham, 2013). THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 12
Two of the studies simply compiled current scientific literature on the subject of NAS
(Hudak et al., 2012; Raffaeli et al., 2017). Topics described in these studies included clinical presentation, diagnostic strategies, and types of nonpharmacologic and pharmacologic therapy.
Most importantly, these studies weighed current evidence to determine when treating NAS with pharmacologic therapies is necessary. The current work in this area is based on research using strong methodology. Therefore, the studies provide a good basis for developing policy and interventions.
Sample Size
Fourteen studies followed two comparison groups during a specific length of time. For seven of the 14 studies, which used a group of formula-fed neonates and a group of breastfed neonates, the sample size ranged from 16 to 437 neonates (Abdel-Latif et al., 2006; Dryden et al., 2009; Isemann et al., 2011; Jansson et al., 2008; Liu et al., 2015; O’Connor et al., 2013;
Welle-Strand et al., 2013). For three of the 14 studies, which used a group of neonates who roomed-in with their mothers and a group of neonates who were admitted to the NICU, the sample size ranged from 45 to 952 neonates (Abrahams et al., 2010; Newman et al., 2015;
Ordean et al., 2015). For one of the 14 studies, which used a group with neonates that received pharmacologic treatment and a group with neonates that received nonpharmacologic treatment, the total sample size was 163 neonates with 69 receiving pharmacologic treatment and 94 receiving nonpharmacologic treatment (Holmes et al., 2016). For one of the 14 studies, which used a group of neonates who received buprenorphine and a group of neonates who received morphine, the total sample size was 63 neonates with 33 receiving buprenorphine and 30 receiving morphine (Kraft et al., 2017). For one of the 14 studies, which used a group of neonates who received methadone and a group of neonates who received morphine, the total THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 13
sample size was 31 neonates with 15 receiving methadone and 16 receiving morphine (Brown et al., 2015). For one of the 14 studies, which used a group of neonates who received buprenorphine and a group of neonates who received neonatal opium solution (NOS), the total sample size was 26 neonates with 13 receiving buprenorphine and 13 receiving NOS (Kraft et al., 2008).
Three research studies used two comparison groups in which both groups collected data at different periods of time. The control group consisted of a group of neonates suffering from
NAS who were admitted to the NICU, while the comparison group consisted of neonates with
NAS that practiced rooming-in with their mothers. The sample size ranged from 44 to 96 neonates (Abrahams et al., 2007; McKnight et al., 2015; Saiki et al., 2010).
One research study looked at one cohort over a specific length of time (Hodgson &
Abrahams, 2012). The cohort was made up of mother-neonate dyads who were cared for through a rooming-in care program. The total sample size for this study was 295 neonates.
One research study used three comparison groups in which each comparison group had data collected at different periods of time. This study used a comparison group of neonates with
NAS before specific changes in interventions occurred, a comparison group after Baby Friendly
Status (BFS) was implemented, and a comparison group after BFS plus breastfeeding education was implemented (Crook & Brandon, 2017). The total sample size of this study was 200 neonates.
Five of the studies used databases to find research articles relating to the topic at hand
(Bagley et al., 2014; Boucher, 2017; Holmes et al., 2017; Kocherlakota, 2014; Pritham, 2013).
The sample size ranged from 5 to 13 articles included within each systematic review. Two of the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 14
five studies stated that many articles were included within each systematic review, but failed to state a specific sample size.
Two of the studies simply compiled current scientific literature on the subject of NAS
(Hudak et al., 2012; Raffaeli et al., 2017). The first study cited a total of 165 journal articles
(Hudak et al., 2012). The second study cited a total of 64 journal articles (Raffaeli et al., 2017).
These studies utilized a range of sample sizes to create a strong foundation upon which future research can be conducted.
Design and Level of Evidence
While conducting a systematic review, it is important that well designed studies are used in the analyses. Five types of designs were identified after reviewing the studies included in this review: systematic reviews, randomized controlled trials, controlled trials without randomization, retrospective cohort studies, and expert opinions. These designs are ranked on predetermined scales and the strength of the evidence is graded using three areas of expertise: quality, quantity, and consistency (Schmidt & Brown, 2015).
Systematic reviews are marked as a level one evidence because they combine the results of studies and statistically determine the effects of the interventions used (Schmidt & Brown,
2015). These types of studies often use both published and unpublished studies (Schmidt &
Brown, 2015). Five of the studies were systematic reviews (Bagley et al., 2014; Boucher, 2017;
Holmes et al., 2017; Kocherlakota et al., 2014; Pritham, 2013).
Randomized controlled trials are marked as a level two evidence. Three of the studies included in this systematic review were randomized controlled trials (Brown et al., 2015; Kraft et al., 2008; Kraft et al., 2017). Controlled trials without randomization are marked as a level three evidence. Four of the studies were controlled trials without randomization (Crook & Brandon, THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 15
2017; Holmes et al., 2016; Jansson et al., 2008; Newman et al., 2015). Both of these types of trials can be found in nursing literature and help with the promotion of evidence-based practice
(Schmidt & Brown, 2015).
Retrospective cohort studies are marked as a level four evidence. They look at changes in characteristics of a large sample over time (Schmidt & Brown, 2015). Twelve of the studies were retrospective cohort studies (Abdel-Latif et al., 2006; Abrahams et al., 2007; Abrahams et al., 2010; Dryden et al., 2009; Hodgson & Abrahams, 2012; Isemann et al., 2011; Liu et al.,
2015; McKnight et al., 2015; O’Connor et al., 2013; Ordean et al., 2015; Saiki et al., 2010;
Welle-Strand et al., 2013). Expert opinions are marked as a level seven evidence. Two of the studies were considered expert opinions (Hudak et al., 2012; Raffaeli et al., 2017). Although these studies range from strongly designed randomized controlled trials to expert opinion, each study adds to the knowledge amassed in this systematic review and helps researchers better understand NAS.
Findings
This section will describe the specific findings related to the effectiveness of treatments for NAS. Both nonpharmacologic and pharmacologic treatments will be discussed, including breastfeeding, rooming-in care, morphine, methadone, and buprenorphine. Each of these treatments will be examined to determine how they affect the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay.
Breastfeeding.
Of the 28 studies examined in this systematic review, similar findings related to breastfeeding neonates suffering from NAS were identified. A correlation between breastfeeding and a decrease in the severity of NAS in neonates was found in seven of the studies reviewed THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 16
(Abdel-Latif et al., 2006; Bagley et al., 2014; Dryden et al., 2009; Hudak et al., 2012; Isemann et al., 2011; O’Connor et al., 2013; Pritham, 2013). Two of these seven studies found that breastfeeding decreased Finnegan scores, one specifying that the mean score peak decreased from 9.65 to 8.8 (Bagley et al., 2014; O’Connor et al., 2013). The Finnegan scoring system was created in 1975 as a neonatal narcotic withdrawal scoring system (Bagley et al., 2014). It includes 20 items, such as high pitched cries, feeding habits, stools, and is weighted on pathologic severity (Bagley et al., 2014). The higher the score, the more severe the NAS is considered.
One study that showed a correlation between breastfeeding and the severity of NAS in neonates was a systematic review with an objective to provide findings related to the assessment and management of neonates with NAS (Bagley et al., 2014). A total of 13 studies regarding nonpharmacologic interventions were included in the review with seven studies specifically examining the relationship between the neonate feeding method and NAS outcomes (Bagley et al., 2014). The articles were found on PubMed and Cochrane Databases and were published between 1975 and 2013 (Bagley et al., 2014). Since the transfer of methadone and buprenorphine through breastmilk is minimal, breastfeeding is recommended for mothers on opioid maintenance therapy, but it is not recommended for mothers using illicit drugs (Bagley et al., 2014). The review shared how breastfeeding is found to act as an analgesic for neonates
(Bagley et al., 2014). Throughout examination of the studies, it was concluded that predominantly breastfed neonates showed a decrease in Finnegan scores as early as the first nine days of life when compared to formula fed neonates (Bagley et al., 2014). The average Finnegan scores in breastfed neonates compared to formula fed neonates was not calculated in this study.
LOS was shown to decrease by up to 19 days in breastfed neonates, and breastfed neonates had a THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 17
30% decreased need for pharmacologic treatment (Bagley et al., 2014). The correlation of breastfeeding and the decreased need for pharmacologic treatment and LOS will be discussed in further detail in this section.
Eleven studies found that breastfeeding decreases the neonate’s need for pharmacologic treatment (Abdel-Latif et al., 2006; Bagley et al., 2014; Dryden et al., 2009; Holmes et al., 2017;
Hudak et al., 2012; Jansson et al., 2008; Kocherlakota, 2014; Liu et al., 2015; O’Connor et al.,
2013; Pritham, 2013; Welle-Strand et al., 2013). The result of one of those studies was not statistically significant due to a small sample size. Of these 11 studies, seven stated that there was a decrease in the need for pharmacological treatment in breastfed neonates ranging from
6.9% to 50% compared to formula fed neonates (Abdel-Latif et al., 2006; Bagley et al., 2014;
Dryden et al., 2009; Holmes et al., 2017; Liu et al., 2015; O’Connor et al., 2013; Welle-Strand et al., 2013).
Three studies found that breastfeeding decreased the length of pharmacologic treatment in neonates with NAS (Abdel-Latif et al., 2006; Isemann et al., 2011; Welle-Strand et al., 2013).
One of these three studies stated that the length of methadone maintenance therapy in a neonate would decrease from 15 to 8 days if that neonate was breastfed (Isemann et al., 2011). Another of the three studies stated that the length of pharmacologic treatment in neonates who were breastfed was 28.6 days compared to 46.7 days in neonates who were formula fed (Welle-Strand et al., 2013).
If the need for and length of pharmacologic treatment both decreased, LOS would also decrease. This finding was shown by eight studies which indicated that breastfeeding reduces the neonate’s LOS (Abdel-Latif et al., 2006; Bagley et al., 2014; Crook & Brandon, 2017;
Dryden et al., 2009; Holmes et al., 2017; Isemann et al., 2011; Kocherlakota, 2014; Pritham, THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 18
2013). Of these eight studies, five stated that the LOS for breastfed neonates with NAS compared to formula fed neonates with NAS decreased between 2.3 days and 19 days (Abdel-
Latif et al., 2006; Bagley et al., 2014; Crook & Brandon, 2017; Holmes et al., 2017; Isemann et al., 2011).
One study included a quality improvement project to see whether prenatal breastfeeding initiatives would increase breastfeeding rates and decrease LOS in neonates with NAS (Crook &
Brandon, 2017). The study included three groups: a traditional care group that included births from February 2014 to August 2014; a baby friendly status (BFS) group that included births from September 2014 to January 2015; and a BFS plus breastfeeding education group that included births from February 2015 to July 2015. Hospital achieved BFS means that the facility provides great care for neonate feeding as well as mother-neonate bonding. LOS was 18.8 days in the traditional care group, 13.14 days in the BFS group, and 10.41 days in the BFS plus breastfeeding education group. Breastfeeding initiation rates were higher in women who were part of group care as opposed to traditional prenatal care. Sixty-seven point three percent of neonates in the traditional care group needed pharmacologic treatment, 53.9% of neonates in the
BFS group needed pharmacologic treatment, and 34.8% of neonates in the BFS plus breastfeeding education group needed pharmacologic treatment (Crook & Brandon, 2017).
These results demonstrate that detailed breastfeeding education should be provided to all mothers with neonates suffering from NAS (Crook & Brandon, 2017).
In opposition to all previous findings, one study stated there is no benefit to breastfeeding neonates with NAS in regards to NAS scores and the need for pharmacologic treatment (Liu et al., 2015). The study stated that breastfed neonates were found to have an average NAS score of
1.3 compared to formula fed neonates who had an average NAS score of 1.1 (Liu et al., 2015). THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 19
The study also found that the max dose of morphine required was the same for breastfed neonates as formula fed neonates, which was 0.5-0.7 milligrams per kilogram per day (Liu et al.,
2015). This study had a small sample size as well as other limitations that could have affected its results. While it is possible the findings of this study could be supported by future research, this study alone should not lead to the conclusion that breastfeeding is a poor treatment option for neonates with NAS.
Overall, these studies indicate that breastfeeding decreases NAS severity, decreases the need and length of pharmacologic treatment, and decreases LOS. Due to these positive findings, it was also determined that breastfeeding education should be provided to all mothers with neonates suffering from NAS.
Rooming-in care.
Out of the 26 studies used in this systematic review, several of the studies provided findings related to rooming-in care and how it affects neonates with NAS. Seven studies found that rooming-in care decreases the need for pharmacologic treatment (Abrahams et al., 2007;
Boucher, 2017; Hodgson & Abrahams, 2012; McKnight et al., 2015; Newman et al., 2015;
Ordean et al., 2015; Saiki et al., 2010), with one study specifying that rooming-in care decreases the need for oral morphine therapy (Abrahams et al., 2007). These seven studies examined how the need for pharmacologic treatment differed between neonates who roomed-in with their mothers or were cared for in the NICU. The percentage of neonates who needed pharmacologic treatment in rooming-in ranged from 11% to 79.2%, whereas the percentage of neonates who needed pharmacologic treatment who were cared for in the NICU ranged from 45% to 88.7%
(Abrahams et al., 2007; Boucher, 2017; Hodgson & Abrahams, 2012; McKnight et al., 2015;
Newman et al., 2015; Ordean et al., 2015; Saiki et al., 2010). Overall, the percentage of neonates THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 20
who needed pharmacologic treatment was lower by a statistically significant number for those who roomed-in with their mothers.
Four studies found that rooming-in care decreases the length of pharmacologic treatment in neonates with NAS (Abrahams et al., 2007; Bagley et al., 2014; Boucher, 2017; Saiki et al.,
2010). These four studies examined the length of pharmacologic treatment in neonates who roomed-in with their mothers compared to those cared for in the NICU. The length of pharmacologic treatment for neonates who roomed-in with their mothers ranged from 5.9 to 27 days, whereas the length of pharmacologic treatment for neonates cared for in the NICU ranged from 18.6 to 32.5 days (Abrahams et al., 2007; Bagley et al., 2014; Boucher, 2017; Saiki et al.,
2010). Overall, the length of pharmacologic treatment was lower by a statistically significant number for neonates who roomed-in with their mothers.
When the length of pharmacologic treatment decreases for a neonate with NAS, the length of hospital stay has also been shown to decrease. Seven studies found that rooming-in care reduces the neonate’s LOS (Abrahams et al., 2007; Bagley et al., 2014; Boucher, 2017;
Holmes et al., 2016; McKnight et al., 2015; Newman et al., 2015; Saiki et al., 2010). Six of the seven studies compared the LOS in neonates who roomed-in with their mothers and those who were cared for in the NICU. Between these specific six studies, the mean LOS for neonates who roomed-in with their mothers was 12.6 days, whereas the mean LOS for neonates cared for in the
NICU was 25 days (Abrahams et al., 2007; Boucher, 2017; Holmes et al., 2016; McKnight et al.,
2015; Newman et al., 2015; Saiki et al., 2010).
In contrast, two studies found that rooming-in care increases the neonate’s LOS
(Abrahams et al., 2010; Ordean et al., 2015). One of these two studies stated that LOS for neonates who roomed-in with their mothers was 21 days, whereas LOS for neonates who were THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 21
cared for in the NICU was 11 days (Abrahams et al., 2010). The other study found that LOS for neonates who roomed-in with their mothers was 26 days, whereas LOS for neonates who did not room-in with their mothers was between 14 and 16 days (Ordean et al., 2015).
One specific retrospective cohort study examined rooming-in for neonates with NAS across three comparison groups (Abrahams et al., 2007). The first group consisted of 32 neonates who roomed-in with their mothers at Vancouver General Hospital during October 2001 and December 2002 (Abrahams et al., 2007). The second group consisted of 28 neonates who were admitted to a level two nursery at B. C. Women’s Hospital between January 1999 and
September 2001 (Abrahams et al., 2007). The third group consisted of 36 neonates who were admitted to a level two nursery at Surrey Memorial Hospital between January 1999 and
December 2002 (Abrahams et al., 2007). Results from this study showed that rooming-in care was associated with decreased need for pharmacologic treatment with morphine, length of pharmacologic treatment, and LOS. Only 25% of the neonates that roomed-in needed pharmacologic treatment, whereas between 52.8% and 55.3% of neonates admitted to a level two nursery needed pharmacologic treatment (Abrahams et al., 2007). The length of pharmacologic treatment with morphine for neonates who roomed-in with their mothers was 5.9 days compared to 18.6 days for neonates admitted to a level two nursery (Abrahams et al., 2007). The LOS for neonates who roomed-in with their mothers was 11.8 days compared to an average of 24.7 days for neonates admitted to a level two nursery (Abrahams et al., 2007). Besides two outlying studies that found rooming-in care increased LOS, the majority of studies indicate that rooming- in care decreases the need for pharmacologic treatment, decreases the length of pharmacologic treatment, and decreases LOS.
Pharmacologic treatments. THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 22
Four studies regarding pharmacologic treatments for NAS were included in this systematic review (Brown et al., 2015; Kraft et al., 2008; Kraft et al., 2017; Raffaeli et al., 2017).
It is crucial to examine the effects of pharmacologic treatments on neonates with NAS because
50-80% of opiate-exposed neonates require some form of pharmacologic treatment (Raffaeli et al., 2017). For example, the average LOS for neonates with NAS increases from 17 to 23 days when the neonate has to receive pharmacologic treatment (Raffaeli et al., 2017). Therefore, it is important to examine each type of pharmacologic treatment in order to know how each of them affects a neonate’s LOS. These four studies focus on three main pharmacologic treatments: buprenorphine, methadone, and morphine.
Of the four studies regarding pharmacological, three of them focused on comparing buprenorphine treatments to other pharmacological agents, such as morphine and methadone
(Kraft et al., 2008; Kraft et al., 2017; Raffaeli et al., 2017). One of the three studies discussed the nature of the medications themselves, including the pros and cons of buprenorphine, methadone, and morphine (Raffaeli et al., 2017). The study found that treating neonates with buprenorphine decreased the need for pharmacologic treatment, decreased the length of pharmacologic treatment by 40%, and decreased LOS by 24% when compared to treating neonates with morphine (Raffaeli et al., 2017). The study also found that evidence regarding how methadone compared to morphine was conflicting and inconclusive (Raffaeli et al., 2017).
Another one of the three studies showed that the length of pharmacologic treatment with buprenorphine is 13 days shorter than treatment with morphine (Kraft et al., 2017). In addition, the same study found that the LOS for neonates receiving buprenorphine is 12 days shorter than for neonates receiving morphine (Kraft et al., 2017). The last of the three studies compared 26 term neonates with NAS who were randomly assigned to receive buprenorphine or neonatal THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 23
opium solution (NOS) (Kraft et al., 2008). The results showed that the mean length of pharmacologic treatment in the morphine group was 32 days, whereas the mean length of pharmacologic treatment in the buprenorphine group was 22 days (Kraft et al., 2008).
Additionally, the mean LOS for neonates treated with morphine was 38 days, whereas the mean
LOS for neonates treated with buprenorphine was 27 days (Kraft et al., 2008). Overall, these findings point to the conclusion that buprenorphine is a more effective pharmacologic treatment compared to methadone and morphine.
One study compared methadone and morphine pharmacologic treatment in neonates with
NAS (Brown et al., 2015). A total of 31 neonates were randomly selected to receive either methadone or morphine (Brown et al., 2015). The results showed that the length of pharmacologic treatment for neonates treated with methadone was 14 days, whereas the length of pharmacologic treatment for neonates treated with morphine was 21 days (Brown et al., 2015).
Overall, the evidence points towards methadone being a more effective pharmacologic treatment than morphine. However, more research should be done to compare buprenorphine to methadone.
Critical Appraisal of the Evidence
The following sections will examine the limitations of findings, the validity and reliability of the methods and findings, and the limitations across the studies included in this systematic review.
Limitations of Findings
There are several notable limitations to the findings of this systematic review. Due to the recent rise in illicit drug use and relative newness of NAS, only a small amount of research has been performed on NAS in general. As a result, this systematic review was first limited by the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 24
lack of general research on NAS and further limited by the small number of studies directly relevant to the aim of this systematic review. Another limitation was only two databases were searched for relevant studies to include in the systematic review. It is possible that more studies could have been found if databases in addition to PubMed and CINHAL were searched. The findings of this systematic review were limited by the keywords chosen to search PubMed and
CINHAL. It is possible that using additional keywords and combinations of keywords that more studies could have been found. Additionally, the studies selected were free to access by downloading and reading online PDF versions of the studies. More studies could have potentially been included if interlibrary loan, paid sources of research, and physical forms of research were investigated.
Validity and Reliability of the Methods and Findings
Across the studies included in this systematic review, issues have been discovered with the validity and reliability of the methods and findings. In three studies, the Finnegan scoring tool was either used incorrectly or subjectively depending on which healthcare professional was using the scoring tool (Abdel-Latif et al., 2006; Kraft et al., 2008; Newman et al., 2015). In one study, there were a high number of premature neonates included in the study population, which could have skewed the reliability of the study (Abdel-Latif et al., 2006). Three studies noted that not all of the hospitals they gathered data from used the same list of signs and symptoms to diagnose a neonate with NAS (Abrahams et al., 2010; Newman et al., 2015; Welle-Strand et al.,
2013). Thus, the validity of the methods of these studies is decreased because there could have been more or less neonates diagnosed with NAS depending on which list of signs and symptoms were used. Two studies stated they did not know which types of illicit drugs the mothers took during pregnancy and how those different drugs could have affected the severity of NAS in the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 25
neonates as a result (Abrahams et al., 2010; McKnight et al., 2015). Therefore, the validity of the findings of these studies is decreased because it is possible that breastfeeding and rooming-in were more successful in treating NAS since the illicit drugs the mothers were on had less severe effects on the neonates. Two studies noted that the validity of their methods was compromised because there were inconsistencies and/or omissions in their data collection due to documentation issues in patient charts (Isemann et al., 2011; Ordean et al., 2015). One study stated their results may not be universally applicable to pregnant women because the effectiveness of rooming-in may have been affected by whether or not pregnant women received prenatal care (Ordean et al., 2015). One study stated the validity of their methods may have been affected because they used a limited number of attending pediatricians to care for their patients
(Holmes et al., 2016). This means that the methods these pediatricians used to care for neonates with NAS could have negatively affected the outcomes examined in the study. One study noted the validity of their findings could have been affected because the use of methadone or buprenorphine maintenance treatments on top of rooming-in care could have masked the true effects rooming-in care has on neonates with NAS when used on its own (Holmes et al., 2016).
One study stated the reliability of their methods could have been affected because they compared sample groups of different sizes (Abrahams et al., 2007). The same study noted the reliability of their findings could have been affected because they were unable to separate out the specific effects of breastfeeding from the effects of rooming-in care (Abrahams et al., 2007).
Limitations across Studies
Upon reviewing the studies included in this systematic review, several limitations were found to be issues across the studies. Three major limitations found across the studies included no randomized group assignment (Abdel-Latif et al., 2006; Abrahams et al., 2007; Boucher, THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 26
2017; McKnight et al., 2015; O’Connor et al., 2013; Ordean et al., 2015; Saiki et al., 2010), no use of control over the study (Boucher, 2017; Kraft et al., 2008; McKnight et al., 2015;
O’Connor et al., 2013; Ordean et al., 2015), and small study population (Brown et al., 2015;
Crook & Brandon, 2017; Jansson et al., 2008; Kraft et al., 2017; Liu et al., 2015; McKnight et al., 2015; O’Connor et al., 2013). Other limitations found across the studies include not accounting for outside variables (Abrahams et al., 2010; O’Connor et al., 2013), not being able to differentiate between the positive effects of breastfeeding and the effects of skin-to-skin contact during breastfeeding (O’Connor et al., 2013), not knowing how long mothers breastfed their neonates with NAS (Bagley et al., 2014; Welle-Strand et al., 2013), only gathering data from one hospital (Brown et al., 2015; Kraft et al., 2008; Kraft et al., 2017), and not using an ethnically diverse sample population (Brown et al., 2015). These limitations represent areas where those conducting the studies failed to ensure the validity and reliability of their study. These areas of failure should be improved upon with research conducted on NAS in the future.
Recommendations
After an extensive review of twenty-six studies, potential practice and research implications were determined for future studies that may be conducted. Research findings support breastfeeding and rooming-in care as effective treatments for mild to moderate cases of
NAS. Results of the studies show that breastfeeding and rooming-in care decrease the need for pharmacologic treatment, length of pharmacologic treatment, and length of hospital stay. In moderate to severe cases, it is recommended that nonpharmacologic treatments be used in combination with pharmacologic treatments. Combining these two treatments will provide the most effective care in treating NAS symptoms. Three studies showed that methadone is more effective than morphine as a pharmacologic treatment for NAS, however more research should THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 27
be done to compare buprenorphine to methadone (Kraft et al., 2008; Kraft et al., 2017; Raffaeli et al., 2017).
As previously noted, an issue facing nurses today is the heterogeneous standards of care across hospitals globally for treating neonates with NAS. It is recommended that hospitals and healthcare facilities look further into case studies and the possibility of implementing a standard treatment protocol for opioid-dependent neonates with NAS derived from evidence-based practice. Once a standard treatment for NAS is created, it is important to first implement the standard care locally before advancing to a regional or statewide practice. At a local level, it would be easier to implement any changes needed to be done to the standard treatment for NAS before it becomes a regional or statewide practice. In addition, it is recommended that doctors, nurses, and other healthcare professionals be further educated about the treatment and care of neonates with NAS. It is important to have well-informed staff members that use evidence- based practice to effectively care for their patients.
Next, it is recommended that research be done to develop a standard screening process for neonates who are at risk for developing NAS and expecting mothers who have a history or high risk of substance abuse. Along with this new standard of care and screening process, it is recommended that the mothers of opioid-dependent neonates be encouraged to take part in an educational program to teach them the importance of nonpharmacologic practices such as breastfeeding and rooming-in care and the positive impact they have on their child’s health outcomes. These educational programs should also teach mothers who still struggle with substance abuse and addiction how important it is to stop breastfeeding. The transfer of methadone and buprenorphine through breast milk is minimal. Therefore, breastfeeding is recommended for mothers on opioid maintenance therapy, but it is not recommended for mothers THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 28
using illicit drugs (Bagley et al., 2014). These educational programs could be offered in local hospitals as well as in the community. It is recommended that medical treatment, resources, and teaching are made available for mothers to stop abuse of illicit substances.
Finally, it is recommended that further research be done on treatment for NAS to advance future practice. Larger, more inclusive studies would be beneficial to determine the trends and common practices for dealing with cases of NAS. One option would be to conduct more randomized controlled clinical trials as opposed to retrospective studies in order to obtain a more accurate comparison of effective treatment plans. Another option would be to conduct a comprehensive focused review concerning the current standards of care for NAS patients at various local and state institutions to determine which treatments prove to be most effective for relieving symptoms of withdrawal with the least negative consequences. This review could include current as well as previous patient charts and their treatment plans. Further systematic reviews would also be beneficial to accumulate data that is currently available for both pharmacologic and nonpharmacologic treatment of NAS. Other systematic reviews could be more expansive than this systematic review by including data on other pharmacologic and nonpharmacologic treatments not previously covered. Further studies also need to address long- term morbidity related to neonatal drug withdrawal and whether it is increased or decreased by pharmacologic treatment. Future studies should also include whether continuing postnatal drug exposure creates risk of neurobehavioral damage and other morbidities.
Conclusion
Breastfeeding and rooming-in care are effective as stand-alone treatments for most NAS cases with mild to moderate symptoms. Breastfeeding and rooming-in care should also be used in congruence with pharmacologic agents to treat moderate to severe symptoms of NAS unless THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 29
otherwise contraindicated. Buprenorphine and methadone have been shown to be more effective at treating the symptoms of NAS than morphine while further research must be conducted to compare the effectiveness of buprenorphine to methadone. Further research still needs to be conducted on the treatment of NAS to determine long-term effects of drug exposure and advance further practice.
THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 30
References
Abdel-Latif, M. E., Pinner, J., Clews, S., Cooke, F., Lui, K., & Oei, J. (2006). Effects of breast
milk on the severity and outcome of neonatal abstinence syndrome among infants of
drug-dependent mothers. Pediatrics, 117(6), e1163–e1169. doi:10.1542/peds.2005-1561
Abrahams, R. R., Kelly, S. A., Payne, S., Thiessen, P. N., Mackintosh, J., & Janssen, P. A.
(2007). Rooming-in compared with standard care for newborns of mothers using
methadone or heroin. Canadian Family Physician, 53(10), 1722–1730. Retrieved from
http://cfp.ca/content/53/10/1722.long
Abrahams, R. R., MacKay-Dunn, M. H., Nevmerjitskaia, V., MacRae, G. S., Payne, S. P., &
Hodgson, Z. G. (2010). An evaluation of rooming-in among substance-exposed newborns
in British Columbia. Journal of Obstetrics and Gynaecology Canada, 32(9), 866–871.
doi: 10.1016/S1701-2163(16)34659-X
Ashraf, I., Ashraf, S., Asif, J. A., & Basri, R. (2016). Metabolic effects of opiate use during
pregnancy: A reappraisal. International Medical Journal, 23(5), 481–484. Retrieved from
http://web.b.ebscohost.com.ezproxy.uakron.edu:2048
Bagley, S. M., Wachman, E. M., Holland, E., & Brogly, S. B. (2014). Review of the assessment
and management of neonatal abstinence syndrome. Addiction Science & Clinical
Practice, 9(19), 1-10. doi: 10.1186/1940-0640-9-19
Barfield, W., Broussard, C., Yonkers, K., Patrick, S. (2016). Primary prevention and public
health strategies to prevent neonatal abstinence syndrome. Centers for Disease Control
and Prevention. Retrieved from https://www.cdc.gov/grand-rounds/pp/2016/20160816-
neonatal-addiction.html THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 31
Boucher, A. (2017). Nonopioid management of neonatal abstinence syndrome. Advances in
Neonatal Care, 17(2), 84–90. doi: 10.1097/ANC.0000000000000371
Brown, M. S., Hayes, M. J., & Thornton, L. M. (2015). Methadone versus morphine for
treatment of neonatal abstinence syndrome: a prospective randomized clinical trial.
Journal of Perinatology, 35(4), 278–283. https://doi.org/10.1038/jp.2014.194
Crook, K., & Brandon, D. (2017). Prenatal breastfeeding education: Impact on infants with
neonatal abstinence syndrome. Advances in Neonatal Care, 17(4), 299–305.
doi:10.1097/ANC.0000000000000392
Dryden, C., Young, D., Hepburn, M., & Mactier, H. (2009). Maternal methadone use in
pregnancy: Factors associated with the development of neonatal abstinence syndrome and
implications for health care resources. British Journal of Obstetrics & Gynaecology, 116,
665–671. doi:10.1111/j.1471-0528.2008.02073.x
Forray, A. (2016). Substance use during pregnancy. F1000Research, 5, F1000 Faculty Rev–887.
doi:10.12688/f1000research.7645.1
Hodgson, Z. G., & Abrahams, R. R. (2012). A rooming-in program to mitigate the need to treat
for opiate withdrawal in the newborn. Journal of Obstetrics and Gynaecology Canada,
34(5), 475–481. doi:10.1016/S1701-2163(16)35245-8
Holmes, A., Atwood, E., Whalen, B., Beliveau, J., Jarvis, D., Matulis, J., & Ralston, S. (2016).
Rooming-in to treat neonatal abstinence syndrome: Improved family-centered care at
lower cost. American Academy of Pediatrics, 137(6), e1-e9. doi:10.1542/peds.2015-2929
Holmes, A. P., Schmidlin, H. N., & Kurzum, E. N. (2017). Breastfeeding considerations for
mothers of infants with neonatal abstinence syndrome. Pharmacotherapy: The Journal of
Human Pharmacology and Drug Therapy, 37(7), 861–869. doi:10.1002/phar.1944 THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 32
Hudak, M. L., Tan, R. C., Frattarelli, D. A. C., Galinkin, J. L., Green, T. P., Neville, K. A., ...
Couto, J. (2012). Neonatal drug withdrawal. Pediatrics, 129(2), e540-e560. doi:
10.1542/peds.2011-3212
Isemann, B., Meinzen-Derr, J., & Akinbi, H. (2011). Maternal and neonatal factors impacting
response to methadone therapy in infants treated for neonatal abstinence syndrome.
Journal of Perinatology, 31, 25–29. doi:10.1038/jp.2010.66
Jansson, L. M., Choo, R., Velez, M. L., Harrow, C., Schroeder, J. R., Shakleya, D. M., &
Huestis, M. A. (2008). Methadone maintenance and breastfeeding in the neonatal period.
Pediatrics, 121(1), 106–114. doi:10.1542/peds.2007-1182
Kocherlakota, P. (2014). Neonatal abstinence syndrome. Pediatrics, 134(2), e547–e561.
doi:10.1542/peds.2013-3524
Kraft, W. K., Gibson, E., Dysart, K., Damle, V. S., LaRusso, J. L., Greenspan, J. S., … Ehrlich,
M. E. (2008). Sublingual buprenorphine for treatment of neonatal abstinence syndrome:
A randomized trial. Pediatrics, 122(3), e601–e607. https://doi.org/10.1542/peds.2008-
0571
Kraft, W. K., Adeniyi-Jones, S. C., Chervoneva, I., Greenspan, J. S., Abatemarco, D.,
Kaltenbach, K., & Ehrlich, M. E. (2017). Buprenorphine for the treatment of the neonatal
abstinence syndrome. New England Journal of Medicine 376(24), 2341-2348.
doi:10.1056/NEJMoa1614835
Liu, A., Juarez, J., Nair, A., & Nanan, R. (2015). Feeding modalities and the onset of the
neonatal abstinence syndrome. Frontiers in Pediatrics, 3(14), 1-4.
doi:10.3389/fped.2015.00014 THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 33
McKnight, S., Coo, H., Davies, G., Holmes, B., Newman, A., Newton, L., & Dow, K. (2015).
Rooming-in for infants at risk of neonatal abstinence syndrome. American Journal of
Perinatology, 33(5), 495-501. doi:10.1055/s-0035-1566295
Newman, A., Davies, G. A., Dow, K., Holmes, B., Macdonald, J., McKnight, S., & Newton, L.
(2015). Rooming-in care for infants of opioid-dependent mothers: Implementation and
evaluation at a tertiary care hospital. Canadian Family Physician, 61(12), e555–e561.
Retrieved from http://web.a.ebscohost.com.ezproxy.uakron.edu
O’Connor, A. B., Collett, A., Alto, W. A., & O’Brien, L. M. (2013). Breastfeeding rates and the
relationship between breastfeeding and neonatal abstinence syndrome in women
maintained on buprenorphine during pregnancy. Journal of Midwifery & Women’s
Health, 58(4), 383–388. doi:10.1111/jmwh.12009
Ordean, A., Kahan, M., Graves, L., Abrahams, R., & Kim, T. (2015). Obstetrical and neonatal
outcomes of methadone-maintained pregnant women: A Canadian multisite cohort study.
Journal of Obstetrics and Gynaecology Canada, 37(3), 252–257. doi:10.1016/S1701-
2163(15)30311-X
Patrick, S. W., Davis, M. M., Lehman, C. U., & Cooper, W. O. (2015). Increasing incidence and
geographic distribution of neonatal abstinence syndrome. Journal of Perinatology :
Official Journal of the California Perinatal Association, 35(8), 650–655.
doi:10.1038/jp.2015.36
Pritham, U. A. (2013). Breastfeeding promotion for management of neonatal abstinence
syndrome. Journal of Obstetric, Gynecologic & Neonatal Nursing, 42(5), 517–526.
doi:10.1111/1552-6909.12242 THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 34
Raffaeli, G., Cavallaro, G., Allegaert, K., Wildschut, E. D., Fumagalli, M., Agosti, M., …
Mosca, F. (2017). Neonatal abstinence syndrome: Update on diagnostic and therapeutic
strategies. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy,
37(7), 814–823. doi:10.1002/phar.1954
Saiki, T., Lee, S., Hannam, S., & Greenough, A. (2010). Neonatal abstinence syndrome—
postnatal ward versus neonatal unit management. European Journal of Pediatrics,
169(1), 95-98. doi:10.1007/s00431-009-0994-0
Schmidt, N. & Brown, J. (2015). Evidence-based practice for nurses: Appraisal and application
of research (3rd ed.). Sudbury, MA: Jones & Bartlett Learning.
Welle-Strand, G. K., Skurtveit, S., Jansson, L. M., Bakstad, B., Bjarko, L., & Ravndal, E. (2013).
Breastfeeding reduces the need for withdrawal treatment in opioid exposed infants. Acta
Paediatrica, 102(11), 1060-1066. doi:10.1111/APA.12378
THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 35
Appendix
Systematic Review Table of Evidence (TOE)
APA Formatted Purpose Statement and Setting, Sampling Methods, Design and Findings / Practice & Research Limitations of Reference Research Question and Sample Size Level of Conclusion Implications Findings Evidence 1: Abdel-Latif, M. E., Purpose Statement: To Setting: Royal Hospital Design: Infants in the breast Unless there are The Finnegan Pinner, J., Clews, S., assess the effects of for Women in Randwick, Retrospective milk group had medical scoring system Cooke, F., Lui, K., & breast milk feeding on the New South Wales, cohort study lower Finnegan contraindications to was used to Oei, J. (2006). Effects severity of NAS in a Australia. Level of scores, shorter breastfeeding, women monitor of breast milk on the population of infants of Sampling Method: Evidence: 4 LOS, delayed onset of all infants at risk of withdrawal from severity and outcome drug-dependent mothers Reviewed data from all of of withdrawal NAS should be all types of drugs of neonatal abstinence who are at risk of NAS. the infants of drug- symptoms, and had encouraged to although it is only syndrome among Research Question: Is dependent mothers a decreased need breastfeed. validated to infants of drug- there a difference in the admitted to the Royal for pharmacologic evaluate opiate dependent mothers. severity of NAS and the Hospital for Women treatment than withdrawal Pediatrics, 117(6), need for pharmacologic between 1998 and 2004. infants in the symptoms. There e1163–e1169. doi: treatment of NAS in Sample Size: A total of formula group. could be a threat to 10.1542/peds.2005- infants of drug-dependent 190 consecutive charts Overall, breast milk validity due to the 1561 mothers who consumed were reviewed for intake significantly higher number of breast milk as opposed to maternal and neonatal data reduces the severity premature infants formula? with 105 formula-fed of NAS. in the formula infants and 85 breast milk- group. There was fed infants. no randomized group assignment. 2: Abrahams, R. R., Purpose Statement: “To Setting: One group was Design: Findings: Practice & Research Limitations of Kelly, S. A., Payne, evaluate the effect of from Vancouver General Retrospective Rooming in was Implications: Findings: Non- S., Thiessen, P. N., rooming in (rather than Hospital (VGH). The first Cohort Study found to be Through the random allocation Mackintosh, J., & standard nursery care) on comparison group was Level of associated with a conclusion, we learned of subjects for Janssen, P. A. (2007). the incidence and severity from B. C. Women’s Evidence: 4 significant that treatment for NAS study groups Rooming-in compared of neonatal abstinence Hospital (BCWH). The decrease in need can’t be universally could be a with standard care for syndrome among opioid second comparison cohort for treatment for one particular limiting factor in newborns of mothers exposed newborns and on was from Surrey Memorial the newborn, treatment, due to the the study design. I THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 36
using methadone or the proportion of mothers Hospital (Surrey). shorter hospital impact of lifestyle also noticed the heroin. Canadian who retain custody of Sampling Method: The stay, and more related factors. The sample sizes for Family Physician, their babies at hospital study used women who likely to be article states, “These the different 53(10), 1722–1730. discharge” (p. 1723). during pregnancy used discharged in their results should groups were not http://cfp.ca/content/5 Research Question: Is heroin or methadone mother’s custody. encourage further the same, which 3/10/1722.long there a decrease on the between October 2001 and Lifestyle related study in the context of could have incidence and severity of December 2002. The first factors a randomized design possibly skewed NAS seeing among comparison group included significantly with prognostic the results. The opioid exposed newborns a historical cohort of every impacted the stratification on study could not and on the number of third woman who gave outcomes of the breastfeeding” (p. separate the mothers who retain birth between January study. 1730). Along with effects of rooming custody of their babies 1999 and September 2001 When the study this, under care of in from those of with the intervention of who used heroin or restricted their nursing and medical breastfeeding, so rooming, compared to a methadone or whose analysis to non- staff, rooming in they should historical cohort and a babies had NAS breastfeeding should be replicate the study concurrent cohort. symptoms. The second women, implemented more for in a large sample comparison group included significantly fewer a safe intervention for of women not all women who were under of the rooming in NAS. breastfeeding to the same category as newborns required explore outcomes above, between January admission to a independently 1999 and December 2002. level 2 or 3 linked with Both comparison groups, nursery. It was rooming in. . had babies separated from stated that their mothers during the breastfeeding in first week of life. this population Sample Size: A total of 96 might be delayed women were in the study, onset of NAS. 32 from VGH, 28 from BCWH, and a 36 from Surrey. . 3: Abrahams, R. R., Purpose Statement: To Setting: Fir Square unit of Design: The rooming-in Rooming-in is valuable The study could MacKay-Dunn, M. H., determine if an BC Women’s Hospital, Retrospective group had a to the care of not report how Nevmerjitskaia, V., interdisciplinary rooming- Royal Columbian, Victoria cohort study significant decrease substance-exposed morphine MacRae, G. S., Payne, in model of care affects General, Surrey Memorial, Level of in admission and infants. Future areas of administration S. P., & Hodgson, Z. clinical and psychosocial Matsqui-Sumas- Evidence: 4 length of stay in the study include changed neonatal THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 37
G. (2010). An outcomes in substance- Abbotsford General, NICU, an increased performing an outcomes because evaluation of exposed newborns. Burnaby General, St. chance of receiving economic evaluation this variable rooming-in among Research Question: Is Paul’s, Richmond General, breast milk during for providing wasn’t recorded. substance-exposed there a difference in Lion’s Gate, Royal Inland, their hospital stay, appropriate care to The presence or newborns in british clinical and psychosocial Kelowna General, and an increased substance-using absence of columbia. Journal of outcomes between Nanaimo Regional chance of being women and examining neonatal Obstetrics and substance-exposed General, and Prince discharged home whether rooming-in withdrawal Gynaecology Canada, newborns whose care George Regional. with their mothers. influences morphine symptoms is 32(9), 866–871. doi: follows a traditional Sampling Method: The standard care administration for considered 10.1016/S1701- standard care model as Reviewed data from all group was found to neonatal withdrawal. unreliable because 2163(16)34659-X compared to an neonates of women who have a significantly institutions vary interdisciplinary rooming- used substances during shorter length of on their reporting in model of care? pregnancy that delivered in stay on average (11 method. The study British Columbia between days compared to was unable to October 1, 2003 and 21 days in the report which types December 31, 2006. rooming-in of substances were Neonates and their mothers group).There was used during were put into two groups no significant pregnancy, which based on whether they difference between could affect the gave birth at BC Women’s the two groups with comparability of Hospital (where rooming- respect to neonatal the two groups. in care was received) or withdrawal elsewhere in British symptoms. Columbia (where standard care was received). Sample Size: There were a total of 952 substance- exposed neonates with 355 in the rooming-in group and 597 in the standard care group. 4: Bagley, S. M., Purpose Statement: Setting: Articles that were Design: Findings: Four of Practice & Research Limitations of Wachman, E. M., “The objective of this used in this systematic Systematic the studies showed Implications: Findings: Studies Holland, E., & Brogly, review is to summarize search were found on Review length of hospital This systematic review often didn’t S. B. (2014). Review available PubMed and the Cochrane Level of stay three to clearly showed through differentiate THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 38
of the assessment and evidence on the Database. The articles Evidence: 1 nineteen days multiple articles that between management of assessment and were published between shorter in breastfed breastfeeding and expressed breast neonatal abstinence management of infants 1975 and November 15, infants. Four of the rooming in help milk and syndrome. Addiction exposed to opioids in 2013. studies showed 30 neonates with NAS. breastfeeding, Science & Clinical utero, including Sampling Method: percent decrease in Due to these findings, they did not Practice, 9(19), 1-10. assessment Finding articles using pharmacologic it is crucial for compare doi: 10.1186/1940- tools used for NAS specific keywords. For treatment for NAS. hospitals to all start exclusive 0640-9-19 scoring, nonpharmacologic One study found implementing these breastfeeding nonpharmacologic treatment, they included breastfed infants interventions by versus interventions, studies composed of showed signs of teaching their staff on combination and pharmacologic cohort, case series, case withdrawal how to implement feeding and management of NAS” (p. control, and randomized significantly later them. The article stated neonates fed with 2). controlled trials. than formula fed that low breastfeeding formula only. Research Question: Sample Size: 13 of the infants. rates in this population Duration of What does published 879 articles pertaining to In regards to are likely due to breastfeeding was English-language nonpharmacologic rooming in, two feeding difficulties in also not defined. literature have to say interventions were studies showed these infants. This may Bias was also about assessment of NAS, included in this review. overall decreased open up a window for introduced due to as well as length of hospital learning how to help the fact that nonpharmacologic stay and duration these neonates with criteria for interventions and of therapy. feeding difficulties. permitting pharmacologic treatments These Further studies should breastfeeding for NAS? interventions also focus on how to were not increase bonding increase rates of described in every and help normalize rooming in and study. the postpartum breastfeeding. process for women with opioid history who may feel vulnerable and stigmatized. 5: Boucher, A. (2017). Purpose Statement: To Setting: PubMed, Ovid Design: Several studies Randomized controlled This study is Nonopioid examine the effectiveness Medline, Embase, and Systematic concluded that trials should be nonrandomized management of of rooming-in care and CINAHL Review infants with NAS performed in the future and uncontrolled. neonatal abstinence acupuncture as Sampling Method: The Level of who receive in order to determine THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 39
syndrome. Advances nonpharmacologic above databases were Evidence: 1 rooming-in care the necessary in Neonatal Care, treatments to decrease the searched for primary have a decreased components of a 17(2), 84–90. doi: amount of postpartum sources on rooming-in care likelihood of rooming-in care model 10.1097/ANC.000000 neonatal opioid exposure and acupuncture as needing for NAS treatment. In 0000000371 and length of hospital treatments for NAS pharmacologic the present, healthcare stay. Sample Size: Eight treatment; even providers should be Research Question: Is research studies were when encouraged to offer there a difference in chosen to be examined in pharmacologic rooming-in care to amount of postpartum this systematic review. treatment is needed, postpartum mothers neonatal opioid exposure length of hospital with infants at risk for and length of hospital stay and opioid NAS. stay in neonates who exposure is receive rooming-in care decreased. and acupuncture? 6: Brown, M. S., Purpose Statement: To Setting: The Neonatal Design: Findings: Length Practice & Research Limitations of Hayes, M. J., & compare the length of Intensive Care and Randomized of treatment was Implications: A Findings: This Thornton, L. M. methadone and morphine Pediatric Inpatient units at Controlled significantly multicenter trial study was a single (2015). Methadone treatment for Neonatal Eastern Maine Medical Trial reduced for should be performed site pilot and was versus morphine for Abstinence Syndrome. Center. Level of neonates treated to enable the findings unable to include treatment of neonatal Research Question: Is Sampling Method: Evidence: 2 with methadone of the study to be as many neonates abstinence syndrome: there a difference in the Mothers in labor who were (14 days) generalized to the in the study as a prospective length of treatment for admitted between January compared to neonate population. previously hoped. randomized clinical Neonatal Abstinence 2011 and October 2012 neonates treated The small sample trial. Journal of Syndrome between were included in the study with morphine (21 size means that Perinatology, 35(4), methadone and if they met the following days). Neonates findings cannot be 278–283. morphine? criteria: “(i) prenatal treated with generalized to the https://doi.org/10.1038 exposure to prescribed methadone had a population. /jp.2014.194 methadone reduced need for a Findings could or buprenorphine, (ii) rescue drug have been meeting our NAS compared to affected by the treatment criteria, (iii) neonates treated fact that maternal adjusted gestational age of with morphine; methadone doses > 350/7 weeks assessed however, this at birth were from best menstrual, finding wasn’t lower in the obstetrical and physical statistically neonates treated THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 40
exam criteria, and (iv) significant. with methadone. otherwise medically stable Additionally, the in the opinion of the sample population attending neonatologist” was mostly (p. 279). Mothers and their European infants who qualified were American and then randomly assigned to therefore not receive treatment with ethnically diverse. either morphine or methadone. Sample Size: 198 mother- infants pairs were screened for inclusion in the study. Only 31 neonates met the inclusion criteria. 7: Crook, K., & Purpose Statement: “To Setting: An outpatient OB Design: Findings: Average Practice & Research Limitations of Brandon, D. (2017). increase breastfeeding clinic. Controlled LOS for infants Implications: Due to Findings: The Prenatal breastfeeding rates and decrease Sampling Method: Infants Trials without decreased from results suggest that small sample education: Impact on hospital length of stay for in the study were divided Randomizatio 18.8 days in the prenatal education cannot make it infants with neonatal infants with NAS through into three groups; baseline n baseline group, to may contribute to an possible to infer abstinence syndrome. prenatal breastfeeding status was births from Level of 13.1 days in the increase in infants direct impact of Lippincott Williams & initiatives” (p. 299). February 2014 to August Evidence: 3 BFS group, to 10.4 with NAS receiving the intervention. Wilkins, 14(4), 299- Research Question: 2014, baby friendly status days in the BFS breast milk, which 305. doi: Would prenatal (BFS) was births from with additional results in a decrease in 10.1097/ANC.000000 breastfeeding initiatives September 2014 to January breastfeeding hospital length of stay, 0000000392 for mothers with infants 2015, then BFS plus education group. prenatal education suffering from NAS breastfeeding education Additionally, needs to be more increase breastfeeding initiative were births from infants who stressed about in the rates and decrease length? February 2015 to July received more than community. 2015. 50 percent human Sample Size: A total of milk predicted to 200 infants were included have a LOS that in the study. was 2.78 days shorter than infants who received all THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 41
formula. 8: Dryden, C., Young, Purpose Statement: Setting: An inner city Design: Findings: Practice & Research Limitations of D., Hepburn, M. and “To investigate factors maternity hospital, Retrospective Breastfeeding for Implications: Findings: The Mactier, H. (2009). associated with the Princess Royal Maternity Cohort Study greater than or Learning preterm article could have Maternal methadone development of NAS and in Glasgow, United Level of equal to 72 hours infants have a hard compared health use in pregnancy: to assess the implications Kingdom. Evidence: 4 was associated time suckling, and care resources Factors associated for health care resources Sampling Method: The with decreasing the many drug misusing now provided for with the development of infants born to drug article presents data over a odds of the neonate mothers choose not to NAS, compared of neonatal abstinence misusing women” (p. 3 year period, from needing treatment breastfeed due to to those provided syndrome and 665). January 2004 to December for NAS by 50 social prejudice, we in the past, to implications for health Research Question: Is 2006 to a large cohort of percent, which need to increase have a care resources. British the implications provided drug misusing mothers. decreases their programs to help these comparison Journal of Obstetrics by healthcare resources Sample Size: This article hospital stay. The causes. The public group. & Gynaecology, 116, helping infants born to collected data for 437 article states needs to learn the 665–671. drug misusing women? infants and 440 mothers. breastfeeding importance of this doi:10.1111/j.1471- soothes agitated intervention. We need 0528.2008.02073.x infants, and the appropriate support drugs taken by the services in the mom are excreted community as well, in the milk, because 50 percent decreasing the neonates failed to effects of attend outpatient withdrawal. appointments. Postnatal stay was recommended for intensive parenting support. 9: Hodgson, Z. G., & Purpose Statement: Setting: Fir Square, a Design: Findings: Practice & Research Limitations of Abrahams, R. R. “...to explore the effect of combined care unit within Retrospective “...significant Implications: Findings: (2012). A Rooming-in our rooming-in protocol BC Women’s Hospital, cohort study positive Rooming-in is a safer Recommends Program to Mitigate on the need to treat mother-child dyads Level of relationship and more beneficial looking into illicit the Need to Treat for withdrawal in the opiate- between 10/01/2003- Evidence: 4 between maternal alternative to the drug use and Opiate Withdrawal in exposed newborn” (p. 12/31/2006. methadone dose at current standard methadone the Newborn. Journal 475). Sample Method: Mothers delivery, ‘other practice of separating relationship over of Obstetrics and Research Question: selected during a certain opiate’ use, and mother and opioid- the course of the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 42
Gynaecology Canada, Does this rooming-in study period. breastfeeding and dependent infant. “The pregnancy to treat 34(5), 475–481. program help reduce the Sample Size: 295 women the need to treat current study suggests infant opioid doi:10.1016/S1701- amount of maternal between the age of 27.5 +/- the neonate for a useful role for withdrawal. 2163(16)35245-8 methadone required to 6.2 years, 295 neonates. withdrawal...mater rooming-in in treat opiate withdrawal in nal methadone mitigating the newborns? dose at relationship between delivery...related to maternal methadone the duration of dose and the need to pharmacological treat the newborn for treatment of the opiate withdrawal” (p. neonate” (p. 475). 480).
10: Holmes, A., Purpose Statement: Setting: Dartmouth- Design: Findings: Practice & Research Limitations of Atwood, E., Whalen, “To determine how to Hitchcock, a Children’s Controlled For infants with Implications: While Findings: B., Beliveau, J., Jarvis, improve the care of Hospital, which provides Trials without NAS treated with achieving the The same six D., Matulis, J., opioid-exposed newborns inpatient, critical care, and Randomizatio the new outcomes they have pediatricians were Ralston, S. (2016). by involving families, pediatric specialty services n implementations, hoped for, they also attending to the Rooming-in to treat standardizing assessment to most of New Hampshire Level of LOS was reduced saw positive family patients. Mother’s neonatal abstinence and treatment, and and a portion of Vermont. Evidence: 3 from 23 days to 12 engagement, increased in the hospital syndrome: Improved transitioning to rooming- Sampling Method: The days, system costs family preparation and service area are family-centered care in for the full hospital research included all birth decreased by more involvement, and maintained on at lower cost. stay” (p. e2). hospitalizations between than half. Costs are trained clinical teams buprenorphine American Academy of Research Question: Is March 2012 and February decreased not only better on how to take more commonly Pediatrics, 137(6), e1- there a difference in 2015, using patients with because the LOS is care of these patient than methadone, e9. length of stay and reported or laboratory decreased, but due situations. These which is seen doi:10.1542/peds.2015 hospital costs when a confirmed maternal opioid to the rooming in outcomes are major with a shorter -2929 coordinated program for use. model. Critical findings in the nursing length of NAS is implemented, Sample Size: Began with a care beds no longer realm, and shows that treatment. which includes pilot group of 10 opioid have to be used for involving families, Rooming-in standardized scoring, dependent women, then this condition, standardizing program socially weaning of medications,, expanded it for all infants. which greatly assessment and acceptable in and a calm rooming in 163 newborns treated for decreases care treatment, and Hampshire and environment, compared to NAS was used in the costs. rooming in for a full Vermont because infants treated without study. 69 newborns hospital stay should be they do not THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 43
this program being received pharmacologic seen in more hospitals impose implemented? treatment, while 94 in the future. mandatory foster newborns did not require care placement pharmacological treatment for opioid and just focused on the exposed interventions of the study. newborns, unlike These included standardize other states. scoring, rooming in, prenatal family education, and environmental management. 11: Holmes, A. P., Purpose Statement: To Setting: Retrieved from Design: Findings: Practice & Research Limitations of Schmidlin, H. N., & identify different benefits databases. Systematic Breastfeeding Implications: Findings: Kurzum, E. N. (2017). of breastfeeding infants Sample Method: Multiple review promotes weight “Clinicians can play Barriers to study Breastfeeding with NAS to reduce studies where some infants Level of gain, skin-to-skin an important role in include considerations for withdrawal syndromes are breastfed and some are Evidence: 1 contact, and the identifying, inconsistent and mothers of infants and determine the formula fed. Each article mother-infant promoting, and inaccurate data with neonatal clinician's role in has its own requirements to bond. “…infants counseling mothers of that causes abstinence syndrome. promoting, identifying, determine which infants with NAS who infants with NAS healthcare Pharmacotherapy: and counseling the were formula fed and were fed primarily regarding providers to The Journal of Human mothers. which were breastfed. breast milk breastfeeding” (p. continue to Pharmacology and Research Question: Sample Size: Reviewed compared with 868). Monitor for discourage drug- Drug Therapy, 37(7), What role does the five studies with a focus on those fed formula rebound NAS and dependent 861–869. clinician have in breastfeeding compared to had a later onset of mothers continuing to mothers from doi:10.1002/phar.1944 advocating for mothers to formula feeding. NAS (10 vs 3 days, abuse substances. breastfeeding. breastfeed the infants p<0.001), required Social prejudice born with NAS? pharmacologic against the treatment less often mothers is also (52.9% vs 79%, another barrier to p<0.001), and had treatment. a shorter length of stay (LOS) (15 vs 19 days, p=0.049)” (p. 862).
THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 44
12: Hudak, M. L., Purpose Statement: Setting: Multiple hospitals Design: Findings: “Drug Practice & Research Limitations of Tan, R. C., Drugs, T. To explore “therapeutic and healthcare clinics Expert Opinion therapy is indicated Implications: Each Findings: C. O., & Newborn, T. options for treatment of Sample Method: Level of to relieve moderate clinic should establish “Studies have not C. on F. A. (2012). withdrawal” and Reviewing scientific Evidence: 7 to severe signs of a threshold level for addressed Neonatal drug determine evidence-based research on the subject of NAS and to total opioid exposure, whether long- withdrawal. management practices of NAS prevent have weaning protocol term morbidity Pediatrics, 129(2), the infant with NAS (p. Sample Size: N/A complications such for infants exposed to related to neonatal e540–e560. 1). as fever, weight opioids, and monitor drug withdrawal doi:10.1542/peds.2011 Research Question: loss, and seizures if for S/S of withdrawal is decreased by -3212 What are the current an infant does not 24 hours after pharmacologic evidence-based practices respond to a discontinuing an management of for treatment and committed opioid. Have protocol affected infants, management of NAS? program of and screening in place or whether nonpharmacologic at nurseries for S/S of continued support” (p. e548). NAS or risk of postnatal drug “When possible, developing exposure and if not withdrawal. augments the risk otherwise of contraindicated, neurobehavioral mothers who and other adhere to a morbidities. It is supervised drug possible that treatment program pharmacologic should be therapy of the encouraged to infant may breastfeed so long introduce or as the infant reinforce a continues to gain maternal weight. disposition to rely Breastfeeding or on drugs for the the feeding of treatment of human milk has infant discomfort been associated or annoying with less severe behavior” (p. NAS that presents e548). THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 45
later and less frequently requires pharmacologic intervention” (p. e548). 13: Isemann, B., Purpose Statement: To Setting: In the newborn Design: Findings: Shorter Practice & Research Limitations of Meinzen-Derr, J., coordinate a managed intensive care unit at The Retrospective median duration of Implications: Findings: The Akinbi, H. (2011). care plan for opiate University Hospital in Cohort Study methadone therapy Through the study, retrospective Maternal and neonatal dependent women that Cincinnati, Ohio. Level of in both preterm they taught the women study had factors impacting reduces the public health Sampling Method: All Evidence: 4 and term infants not to abruptly stop incomplete data response to methadone burden posed by NAS, by newborns that received were found with infant’s ingestion of collection from therapy in infants outlining the risks of fetal methadone therapy for infants feed breast breast milk, for it the medical treated for neonatal drug exposure, NAS at The University milk. Breast milk could precipitate records, and abstinence syndrome. emphasizes the benefits Hospital between January feed infants had a rebound withdrawal. I stated that infants Journal of of providing mother 2002 and December 2007. shorter hospital would like to see more rehospitalized for Perinatology, 31, 25– breast milk to infants, and Sample Size: 128 infants, stay, 3 to 51 days, future studies withdrawal 29. cautions against rapidly with a total of 1528 compared to identifying infants at symptoms may doi:10.1038/jp.2010.6 weaning infants from methadone treatment days formula fed infants risk for rebound NAS. have been 6 mother breast milk. were included in the hospital stay The article states underestimated. Research Question: Is analyses. Of the 128 ranging from 9 to providers should aim Also, since the there a reduced public infants, 56 of the term 43 days. Through for a individualized article was about health burden posed by infants had breast milk the study they approach to initial benefits of NAS when opiate available to them. estimated that the methadone dosing, breastfeeding to dependent women are intake of which takes into help with NAS, treated through a methadone from consideration the the article stated managed care plan? breast milk could gestational age and the they may have be as high as availability of breast possibly 0.05mg kg daily, milk as a primary contributed to which may help nutrition. Due to this decreased length prevent or decrease finding, I think it is of hospital stay the severity of important for more due to bias in NAS. physicians taught on initiating therapy. proper methadone dosing. 14: Jansson, L. M., Purpose Statement: To Setting: N/A Design: “More infants in the While it appears that The study’s results THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 46
Choo, R., Velez, M. evaluate concentrations of Sampling Method: Controlled control (formula- the benefits of are based on very L., Harrow, C., methadone in breast milk Subjects enrolled in a Trial without fed) group required breastfeeding outweigh small group sizes. Schroeder, J. R., as well as maternal and substance abuse treatment Randomizatio pharmacologic the effect a small The results exhibit Shakleya, D. M., & infant plasma among program for pregnant and n treatment for NAS concentration of bias due to the Huestis, M. A. (2008). methadone-maintained postpartum drug- Level of (4 infants, methadone found in need for Methadone breastfeeding women dependent women between Evidence: 3 compared with 1 breast milk might have, reconstitution of maintenance and compared to formula- January 2001 and breastfed infant), more research should several infant breastfeeding in the feeding women. September 2005. Subjects but this association be performed to plasma specimens neonatal period. Research Question: Is were included in the study was not statistically determine the long- that dried out Pediatrics, 121(1), there a difference in if they met the following significant” (p. term effects of while in storage. 106–114. concentrations of criteria: “Single daily dose 110). A substantial methadone on This caused those doi:10.1542/peds.2007 methadone in breast milk of methadone, absence of increase in developing infants. concentration -1182 as well as maternal and significant fetal or methadone Overall, the study values to be infant plasma among maternal complications, concentrations in recommends overestimated. methadone-maintained singleton pregnancies, breast milk was breastfeeding among breastfeeding women expressing a desire to noted over time. pregnant women compared to formula- breastfeed at routine “There was no maintained on feeding women? obstetric care visits, significant methadone. abstinence from licit/illicit correlation between substance use after 32 maternal methadone weeks gestation, and doses and infant compliance with program plasma methadone standards” (p. 107). concentrations” Sample Size: Eight (p.112). There was women met the criteria and no association were called the between neonatal breastfeeding group. These methadone women were compared to concentrations and eight control subjects who breastfeeding or were called the formula- receiving feeding group. pharmacologic treatment for NAS. 15: Kocherlakota, P. Purpose Statement: Setting: Children’s Design: Findings: Practice & Research Limitations of (2014). Neonatal To explain NAS, its Hospital at New York Systematic “Breastfeeding Implications: Assess Findings: abstinence syndrome. history, clinical Medical College, Valhalla, Review may decrease the neurological and Healthcare bias THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 47
Pediatrics, 134(2), presentations, treatments, New York. Level of incidence of NAS, motor function, against mothers e547–e561. and discharge/follow-up. Sample Method: Evidence: 1 the need for psycho-behavioral who breastfeed doi:10.1542/peds.2013 Research Question: Complication of multiple pharmacological behavior, growth and while on opioid -3524 What is Neonatal journal articles. treatment, and the nutrition for agonist treatment. Abstinence Syndrome? Sample Size: 187 journal length of the abnormalities and Mothers don’t articles. hospital stay” (p. setbacks. continue e555). breastfeeding “Nonpharmacologi after they leave cal therapy is the the hospital. first option in all cases, and may suffice in cases of mild withdrawal. Nonpharmacologic al therapy is easily acceptable, less expensive, and less controversial” (p. e553). 16: Kraft, W. K., Purpose Statement: To Setting: Thomas Jefferson Design: Findings: The Practice & Research Limitations of Gibson, E., Dysart, K., determine the viability, University Hospital in Randomized average length of Implications: Findings: This Damle, V. S., safety, and effectiveness Philadelphia. Controlled treatment for Although the findings study was a single LaRusso, J. L., of treating neonates with Sampling Method: Trial neonates treated of this study suggest site pilot study, Greenspan, J. S., … Neonatal Abstinence Mothers in labor who were Level of with that buprenorphine is which means that Ehrlich, M. E. (2008). Syndrome with admitted between April Evidence: 2 buprenorphine was viable, safe, and findings cannot be Sublingual sublingual buprenorphine 2005 and January 2008 22 days compared effective treatment, a generalized to the buprenorphine for compared to the standard were included in the study to 32 days for double-blind clinical neonate treatment of neonatal care neonatal opium if they met the following neonates treated trial with a larger population as a abstinence syndrome: solution (NOS). criteria: “>37 weeks’ with NOS. The sample size should be whole. a randomized trial. Research Question: Is gestation, exposure average length of conducted in order for Additionally, bias Pediatrics, 122(3), there a difference in to opioids in utero, and hospital stay was findings to be found couldn’t be e601–e607. viability, safety, and demonstration of signs and 27 days for statistically completely https://doi.org/10.1542 effectiveness of treating symptoms of NAS that neonates treated significant. eliminated during /peds.2008-0571 neonates with Neonatal required treatment” (p. with scoring of Abstinence Syndrome e602). Mothers and their buprenorphine symptom severity. THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 48
with sublingual infants who qualified were compared to 38 buprenorphine compared then randomly assigned to days for neonates to neonatal opium receive either sublingual treated with NOS. solution (NOS)? buprenorphine or NOS. Unfortunately, Sample Size: 26 neonates neither of these met the inclusion criteria. findings was 13 neonates were treated statistically with buprenorphine and 13 significant. were treated with NOS. 17: Kraft, W. K., Purpose Statement: “In Setting: Thomas Jefferson Design: Findings: Practice & Research Limitations of Adeniyi-Jones, S. C., the single-site, University Hospital in Randomized Buprenorphine is Implications: This Findings: Some Chervoneva, I., randomized, double- Philadelphia Controlled useful for studies results shares limitations of this Greenspan, J. S., blind, double-dummy Sampling Method: Trial treatment of the benefits of study include the Abatemarco, D., Blinded Mothers in this study were Level of neonatal buprenorphine over small sample size Kaltenbach, K., Buprenorphine or enrolled in an outpatient Evidence: 2 abstinence morphine drug, and the single Ehrlich, M. E. (2017). Neonatal Morphine methadone treatment syndrome due to showing the center design. The Buprenorphine for the Solution program from October 31, its large buprenorphine is study also treatment of the (BBORN) trial, we 2011 and May 29, 2016. therapeutic index beneficial to the excluded preterm neonatal abstinence compared sublingual 30 infants were randomly for respiratory treatment of NAS. infants and those syndrome. New buprenorphine with oral assigned to receive depression, along With these results, with England Journal of morphine with respect buprenorphine, while 28 with having a long buprenorphine should benzodiazepine Medicine 376(24), to the duration of were randomly assigned to half-life. Primary be used more often in exposure in utero, 2341-2348. treatment in infants with receive morphine. outcomes included these cases, and more causing the results doi:10.1056/NEJMoa1 the neonatal abstinence Sample Size: 63 infants a decrease of research should be to be invalid to 614835 syndrome” (p. 2342). duration of involved in this topic. this population. Research Question: treatment with Which pharmacologic buprenorphine, treatment decreases the with the mean duration of treatment in number of days 13 infants with NAS, days decrease buprenorphine or compared to those morphine? treated with morphine. A decrease LOS of a mean of 12 days THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 49
was found with buprenorphine. 18: Liu, A., Juarez, J., Purpose Statement: Setting: Two birthing Design: Findings: Practice & Research Limitations of Nair, A., & Nanan, R. “...to compare the impact units in Western Sydney Retrospective “After adjusting Implications: Findings: (2015). Feeding of different feeding from 2000 to 2006. Cohort Study for confounders, Breastfed infants The small sample modalities and the modalities on the onset of Sample Method: Level of there was no reacted to NAS the size of the sample onset of the neonatal NAS” (p. 1). Researchers looked at the Evidence: 4 significant effect of same as those who groups made it abstinence syndrome. Research Question: medical records of 194 the modality of were formula fed. difficult to prove Frontiers in What is the mechanism cases and organized the feeding on the They encourage the advantages of Pediatrics, 3(14), 1-4. behind the beneficial infants within the first 2 rates of NAS breastfeeding unless breastfeeding for doi:10.3389/fped.2015 effect of breast milk? days of life. One group requiring treatment contraindicated in the infants with NAS. .00014 was mainly breastfed while (p = 0.11). mother. Breastfeeding the other was mainly Breastfeeding isn’t negative formula fed. significantly concerning NAS Sample Size: “…194 delayed the onset treatment and has methadone-maintained of NAS (p = 0.04). other positive benefits. mother/infant dyads” (p. The act of 1). breastfeeding in the first 2 days of life had no effect on whether an infant required treatment for NAS when compared to those fed EBM or formula” (p. 1). 19: McKnight, S., Purpose Statement: To Setting: Kingston General Design: The need for Future studies should The study was Coo, H., Davies, G., determine the impact of Hospital in Ontario, Retrospective pharmacologic examine the cost nonrandomized Holmes, B., Newman, rooming-in care for Canada cohort study treatment has a differences between and uncontrolled. A., Newton, L., & infants at risk of NAS on Sampling Method: The Level of strong association rooming-in and The study’s small Dow, K. (2015). the necessity for study population was all Evidence: 4 with the length of admission to the NICU. population Rooming-in for pharmacologic treatment infants considered at risk hospital stay. More research should numbers could infants at risk of and length of hospital of developing NAS. The Rooming-in was be done to test the have made it neonatal abstinence stay. population was split into found to decrease relationship between difficult to syndrome. American Research Question: Is two groups. The first group the need for breastfeeding and statistically detect THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 50
Journal of there a difference in the of infants was born pharmacologic rooming-in. Futures differences Perinatology, 33(5), need for pharmacologic between May 1, 2012 and treatment, decrease research should between the two 495-501. treatment and length of May 31, 2013 as these length of hospital evaluate the possible groups that could doi:10.1055/s-0035- hospitalization for infants infants were admitted to stay, and is barriers to employing have affected the 1566295 at risk of neonatal the NICU. Infants born independent of rooming-in for study’s results. abstinence syndrome between June and August breastfeeding. pregnant substance The study did not (NAS) who take part in a of 2013 were excluded. users and their compare the types rooming-in program The second group of neonates. of drugs used by compared to those who infants was born between the mothers in the receive standard care? September 1, 2013 and two groups. September 30, 2014 as these infants roomed-in with their mothers. Sample Size: There were a total of 44 infants with 24 in the NICU group and 20 in the rooming-in group. 20: Newman, A., Purpose Statement: “To Setting: Kingston General Design: Findings: The Practice & Research Limitations of Davies, G. A., Dow, implement a rooming-in Hospital located in Controlled neonates in the Implications: Due to Findings: There K., Holmes, B., program to support close Ontario. A tertiary care Trials without rooming in cohort the significant might be a Macdonald, J., uninterrupted contact referral centre with a level Randomizatio had significantly findings in this possible source of McKnight, S., & between opioid-dependent 3 NICU. n lower oral research article, it is bias regarding the Newton, L. (2015). women and their infants in Sampling Method: All Level of morphine therapy important for more NAS scoring tool, Rooming-in care for order to decrease the known opioid dependent Evidence: 3 (14.3%) compared hospitals to implement for to quantify infants of opioid- severity of NAS scores, mothers attending the to those admitted neonates rooming in withdrawal dependent mothers: lessen the need for multidisciplinary antenatal directly to the rather than admitting severity, Implementation and pharmacotherapy, and clinics by September 30th, NICU (83.3%). them to the NICU. subjective evaluation at a tertiary shorten hospital stays” (p. 2014. Exclusion criteria if The LOS for those judgment is used care hospital. e555). had planned apprehension rooming in was 7.9 to some degree. Canadian Family Research Question: Is by child protection days, compared to Future research Physician, 61(12), there a difference in services or existence of 24.8 days seen in also has to be e555–e561. Retrieved severity of NAS scores, another neonatal condition those directly done to look at from the need for that would require admitted to the neonatal and http://web.a.ebscohost. pharmacotherapy, or admission to the NICU. NICU. childhood com.ezproxy.uakron.e length of hospital stay Sample Size: 21 women outcomes in the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 51
du with opioid dependent were admitted to a private long run. mothers and their neonates room in the pediatrics unit cared for with the new with their full term infants. rooming in program, 24 women whose babies compared to those not were directly admitted to rooming in? the NICU for direct observation. 21: O’Connor, A. B., Purpose Statement: To Setting: “An integrated Design: “Although not Although initial This study could Collett, A., Alto, W. examine breastfeeding medical and behavioral Retrospective statistically findings are positive, not measure the A., & O’Brien, L. M. rates among opioid- health program for opioid- cohort study significant, more research should effects of (2013). Breastfeeding dependent pregnant dependent women…” (p. Level of preliminary results be done with larger breastfeeding on rates and the women on buprenorphine 384). Evidence: 4 suggest that sample sizes to length of hospital relationship between maintenance treatment Sampling Method: The breastfeeding may determine if stay because other breastfeeding and and to determine the charts of all opioid- attenuate NAS” (p. breastfeeding causes a variables (such as neonatal abstinence effects of breastfeeding dependent pregnant 385). The average statistically significant pregnancy syndrome in women on length, intensity, and women on buprenorphine NAS score and difference in NAS complications maintained on frequency of maintenance treatment likelihood of severity and need for other than NAS) buprenorphine during pharmacologic treatment who were in the integrated pharmacologic pharmacologic were present in the pregnancy. Journal of for neonates with NAS. program from December treatment were treatment. study’s sample. Midwifery & Women’s Research Question: Is 2007 to August 2012 were lower in breastfed Because this study Health, 58(4), 383– there a difference in reviewed. neonates. NAS is nonrandomized 388. length, intensity, and Sample Size: 85 mother- symptoms resolved and uncontrolled, doi:10.1111/jmwh.120 frequency of infant pairs were examined approximately 2 it cannot be used 09 pharmacologic treatment in this study. hours earlier in to determine cause for neonates with NAS breastfed neonates and effect. There who receive breast milk than in non- was information compared to non- breastfed neonates. missing regarding breastfed neonates? why the women in this study chose to begin and/or stop breastfeeding. Additionally, it is hard to differentiate the positive effects of THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 52
breastfeeding from other nonpharmacologic treatments, such as skin-to-skin contact that occurs during breastfeeding. The small sample size, especially regarding the number of neonates in the non-breastfed group, diminished the study’s ability to show statistical significance. THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 53
22: Ordean, A., Purpose Statement: To Setting: The Sheway Design: In the Vancouver Policies should This study is Kahan, M., Graves, L., compare obstetrical and Clinic in Vancouver Retrospective site where rooming- promote maternal- nonrandomized Abrahams, R., & Kim, neonatal outcomes, (which uses rooming-in cohort study in care was used, newborn contact, and uncontrolled. T. (2015). Obstetrical including NAS, among care for infants with NAS), Level of there was a reduced rooming-in care, and There are and neonatal outcomes methadone-maintained the Toronto Centre for Evidence: 4 rate of NICU breastfeeding as inconsistencies of methadone- pregnant women across Substance Use in admission, an methods to decrease and omissions in maintained pregnant three Canadian Pregnancy, and the Herzl increased length of NAS symptoms and the data due to women: A canadian metropolitan cities. Family Practice Centre in hospital stay, and a the need for frequent multisite cohort study. Research Question: Is Montreal (both of which shorter duration of pharmacologic documentation Journal of Obstetrics there a difference in admit infants with NAS to NAS treatment. treatment. issues in patient and Gynaecology obstetrical and neonatal the NICU). These findings are charts. Canada, 37(3), 252– outcomes, including Sampling Method: all consistent with Additionally, the 257. NAS, among methadone- Reviewed the medical the hypothesis that results of this doi:10.1016/S1701- maintained pregnant records of pregnant women rooming-in study may not be 2163(15)30311-X women across three with a history of opioid use decreases the need universally Canadian metropolitan that were eligible for or for treatment of applicable to cities? already receiving newborns with methadone- methadone-maintenance NAS. maintained treatment (MMT) at pregnant women integrated care programs in who have not three Canadian cities from received prenatal 1997 to 2009. care. Sample Size: There were a total of 94 women in the study with 36 from Toronto, 36 from Vancouver, and 22 from Montreal. 23: Pritham, U. A. Purpose Statement: Setting: PubMed, Design: Findings: Practice & Research Limitations of (2013). Breastfeeding “...to educate perinatal CINAHL, and Medline Systematic Breastfeeding is Implications: This Findings: promotion for clinicians and substance Sample Method: In the Review shown to decrease study encourages “Further research management of abuse treatment databases mentioned above, Level of need of treatment, healthcare workers to is needed to neonatal abstinence specialists about NAS the keywords used were: Evidence: 1 LOS, severity, and reassure and educate determine syndrome. Journal of and the interplay of “…opioid dependency in duration of NAS. the mothers of opioid- differences in Obstetric, Gynecologic breastfeeding, skin-to- pregnancy, neonatal It is also shown to dependent infants about NAS between THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 54
& Neonatal Nursing, skin contact, and abstinence syndrome, promote bonding the benefits of neonates who 42(5), 517–526. swaddling on NAS methadone, buprenorphine, and infant breastfeeding, both for were breastfed doi:10.1111/1552- symptom management” neonatal length of stay, attachment the mother and infant. and those who 6909.12242 (p. 517). breastfeeding, methadone in between the were fed pumped Research Question: breast milk, buprenorphine mother and child. breast milk or Should breastfeeding be in breast milk, swaddling, donor milk. The recommended as a long- and rooming-in” (p. 517). safety of term health treatment for Sample Size: Articles breastfeeding high risk mothers and published between January while on their newborn infants 1990 and April 2013. psychotropic with NAS? medications with opioid replacement therapy also needs further exploration” (p. 524). 24: Raffaeli, G., Purpose Statement: Setting: Medical journals. Design: Findings: Practice & Research Limitations of Cavallaro, G., “The aim of this review Sampling Method: Expert Morphine is often Implications: More Findings: Allegaert, K., is to examine recent Reviewing recent and Opinion the first line agent tailored therapy Limitations of Wildschut, E. D., and relevant scientific relevant scientific literature Level of to treat NAS with regarding this study involve Fumagalli, M., Agosti, literature on NAS, to on NAS. Evidence: 7 methadone being pharmacologic no specifically M., Tibboel, D., increase awareness of the Sample Size: N/A another alternative, management should be stating how many Mosca, F. (2017). severe potential impact but its safety done to better articles were Neonatal abstinence of in utero drug exposure profile is not understand the risks reviewed, where syndrome: Update on on the developing totally known. 50- associated with them. they were found, diagnostic and child, and to highlight 80% of opiate Community awareness and the time therapeutic strategies. preventive strategies, exposed neonates of the impact of NAS period these Pharmacotherapy early diagnosis, require on health care will articles were Publications 37(7), educational programs, pharmacologic maybe generate published. 814-823. evidence based management. supportive policies to doi:10.1002/phar.1954 standardized Compared with expand on research management, and methadone, related to this topic. research buprenorphine- Implementation of agendas as priority exposed neonates standard weaning THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 55
issues” (p. 815). have a milder NAS protocols is also Research Question: course. important to research What does recent and more on, for it has a relevant scientific positive impact on literature have to say length of regarding NAS, and pharmacologic evidence based therapy. standardized management? 25: Saiki, T., Lee, S., Purpose Statement: To Setting: King’s College Design: Infants who were Further studies, The largest Hannam, S., & determine if caring for Hospital (KCH) in Retrospective cared for on the particularly limitation to this Greenough, A. (2010). infants with NAS on the Denmark Hill, London, cohort study postpartum unit randomized trials, study was that it Neonatal abstinence postpartum unit with UK Level of with their mother should be performed to was not a syndrome—postnatal their mothers will reduce Sampling Method: Two Evidence: 4 required less examine postpartum randomized trial. ward versus neonatal treatment duration and groups of infants with NAS treatment, a unit management of unit management. length of hospital stay were examined. The first decreased length of infants with NAS. European Journal of when compared to infants group was comprised of all treatment, and a Pediatrics, 169(1), 95. admitted to the NICU or infants with NAS cared for decreased length of doi:10.1007/s00431- neonatal unit. between 2002 and 2005 hospital stay. 009-0994-0 Research Question: Is who were admitted to the there a difference in neonatal unit. The second treatment duration and group was comprised of all length of hospital stay in infants with NAS cared for infants with NAS when between 2006 and 2007 they are cared for on the who remained on the postpartum unit postpartum unit with their compared to in the NICU mother. or neonatal unit? Sample Size: There were 42 infants in the neonatal unit group and 18 infants in the postpartum unit group. 26: Welle-Strand, G. Purpose Statement: “To Setting: Regional Design: Findings: 77 Practice & Research Limitations of K., Skurtveit, S., examine the rate and treatment centres for OMT Retrospective percent of the Implications: Since Findings: Only Jansson, L. M., duration of breastfeeding in Norway, 18 different Cohort Study women in OMT breastfeeding benefits one part of the THE EFFECT OF BREASTFEEDING AND ROOMING-IN CARE ON NEONATAL 56
Bakstad, B., Bjarkø, in a cohort of women in hospitals were used. Level of breastfed. both the mother and study consisted of L., & Ravndal, E. opioid maintenance Sampling Method: “A Evidence: 4 Breastfed neonates child, we need to a prospective (2013). Breastfeeding treatment (OMT) in national cohort of women who prenatally increase the rates design, and the reduces the need for Norwary, as well as the treated with either were exposed to among women in retrospectively withdrawal treatment effect of breastfeeding on methadone or methadone OMT. We need to designed study in opioid exposed the incidence and buprenorphine during required less increase support for maybe have less infants. Acta duration of NAS” (p. pregnancy, and their pharmacotherapy these women. It may accurate data due Paediatrica, 102(11), 1060). neonates born between for NAS. All already be harder for to relying on 1060-1066. Research Question: Is 1999 and 2009” (p. 1060). breastfed neonates them due to lactation recall. Also, the doi:10.1111/APA.123 there a difference in the A standard questionnaire needed less difficulty found in children were 78 duration or incidence of was passed out and pharmacological OMT women and Nas born in 18 NAS as a result of medical information was treatment for NAS associated behaviours different hospitals breastfeeding in a cohort collected to confirm self- compared to those make breastfeeding with different of women in OMT? reported data. who were not more difficult. assessment skills Sample Size: A total of breastfed. of NAS at each. 124 women and children Lastly, the were included in this study. questionnaire did not cover breastfeeding that in depth, so we don’t know how long the women exclusively breastfed for.